Can I switch to insulin and stop Metformin if needed?

Question

Hello doctor,

I have developed type 2 diabetes in the past three years. However, in the last year, I did not require insulin as my sugar levels were normal. I live abroad, and I am on Metformin. Due to COVID-19 and various lockdowns in the country, my sugar levels were out of control. I am now back to my strict diet, exercise, and still taking Metformin 500 mg twice a day.

My morning sugar levels are normal, anywhere between 90 and 133. A test again before lunch very rarely shows high sugar levels. I may need to use my Novolin N injection. If not during lunch, I may have to use 30 minutes before my evening meal. I noticed my eyes are going blurry, and it's hard to see if my sugar levels rise above 150.

A few months back, the retina in my right eye ripped, and I had to do a laser repair. Then the same thing occurred in my left eye. The doctors here did not know to look at the correlation between that and diabetes, nor did I. When testing my blood sugar from Monday through Sunday before each meal, I usually have an average between 90 and 150. I say if it goes above that, then I take 3 to 5 units of insulin.

However, last week before dinner, it pushed up to 248, and I had to take 10 units to get it down. I eat no sugar. I watch my carbs, primarily fruits and vegetables, and do everything I can. The doctor here in this country says that he would like to switch me over to the insulin pen, which is considered a 70/30 distribution.

My question is, do you recommend this insulin pen, even though I have days when my sugar may be acceptable in the morning? Right now, this doctor here in this country is asking me not to take any Metformin or insulin for one week. He wants to see all of my sugar numbers every morning and afternoon so that he can see the pattern of my sugar. Would you follow the same treatment? Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

Diabetes has many complications, so it is not just about bringing down the numbers but also about monitoring and treating complications associated with diabetes. Check your eyes for retinopathy, kidneys with urine albumin creatinine ratio, and check your feet.

Lifestyle modifications are the best treatment for diabetes. Take a low-carbohydrate diet with no added sugar. No sugary juices, bread, rice, pasta, or potatoes. If you cannot stop, at least take as little as possible. Take more vegetables, salads, and fiber. Consume fruits only as a sweet dish. Do not take mangoes, grapes, and bananas. Do not take more than one apple. Strawberries and other berries are fine to take along with peach, apricot, and small amounts of plums.

Intermittent fasting will also help you control your diabetes. You can fast for 16 hours, like taking your dinner at 7 pm and not eating anything after that. Next, you can take breakfast at 11 am. During fasting, drink water and green tea without sugar. You can extend fasting to 24 hours, then 36 hours as your body adapts. You can do fasting two times a week, or as you feel comfortable, it will control your sugar.

Drink more water. Sleep well. Do exercise, such as walking, for at least 30-40 minutes daily. The more you practice these things, the better your control will be. Check your sugar frequently. Your fasting target should be 90-130. Two hours after eating, it should be 150-160. Hemoglobin A1c should be less than 7. These targets can vary in individual patients depending on their diabetes duration and other relevant issues.

In my opinion, it is not a good idea to take insulin after you find out that your sugar is high and then bring it down fast. It creates big fluctuations in your sugar levels, meaning one time it is high, and after a few minutes it is down. This is not good. Actually, you should check your sugar more frequently, once in the morning before breakfast, if it is in the range as

I mentioned above that there is no need to take any insulin. Then, check your sugar before lunch, and the same rule applies. Check it after eating as well. I mean that if your sugar levels are higher after eating only, you should start taking insulin just before meals, like 15-20 minutes before eating, so there should not be a surge in your sugar level.

How much should you take? That depends on two things: how much sugar you eat before eating and how many carbohydrates you are going to eat. But before considering bringing down your sugars after eating, first bring them under control during fasting sugars. It is better to take basal insulin, like Glargine, which comes in the trade name of Lantus, at night. You can start it like six units and then increase every day by 1-2 units if your fasting sugars are higher than 120-130.

If your fasting is within range, then there is no need. If it goes less than 70, then decrease about 3/4 units the next day. Once your fasting sugar is in range, then we concentrate on sugar after eating. That should be near 150. You can start to take Novo Rapids only at your main meal, and take it just before a meal if you find that after eating, your sugars are higher than the range. Your HbA1c should be less than 7. Another important issue is whether you have any of the diabetes complications other than eyes, as you mentioned.

You should check the urine albumin creatinine ratio at least once a year to check how your kidneys are doing. Do you have any heart issues? How about ur blood pressure and cholesterol levels? It is not just about bringing the sugar number down, but also about keeping the whole body healthy, as I mentioned above. Check your diet and lifestyle modifications as above. A low-carbohydrate diet and intermittent fasting, as I mentioned above, will help you a lot. If you could practice it well, I hope you may not even need insulin, and your Metformin will be enough.

I hope this helps.

Kindly revert so I can assist you further.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

I will give you the details about how to use insulin. In my opinion, it is better first you should check your sugars regularly (fasting and before and after meal). Do it for at least three to four days. Then we will be in a better position to see what time your sugars are really high and how much. First option can be to increase the Metformin to its maximum dose of 2 gram daily. Then we can add either another oral medication or go to insulin. Depending upon your sugar levels your preference and feasibility. If Insulin is to be started I think you can use Glargine as a basal insulin and Novorapid as a bolus insulin and it is better than insulin pen 30/70. And I have already explained how to use Lantus and Novorapid.

Our body continuously produces insulin in small amounts. This is called basal insulin. Then the time we eat there is increased surge of insulin which is a bolus insulin. So when we give insulin in patients who have diabetes we try to make it same way. Lantus or Glargine is basal insulin and it remains in the body all the time and it is called basal insulin. It is long-acting. Where as insulin like Novorapid is bolus insulin which is given just before the meals to stop the surge of glucose or sugar levels after eating. It is short acting and starts its work in 15-20 minutes reaches at peak at about 90 minutes and stays in body for four to five hours only. Where is 30/70 is mixture of intermediate acting and short acting insulin and the ratio is fixed and it cannot be changed. It is harder to control sugar with this mixed insulin and you need to be strict in your diet. Basal bolus insulin gives you more flexibility in terms of your diet and you can modify the insulin according to your levels of sugar and content of your meal.

I hope this helps.

Thank you.